ATHENS AREA HEALTH PLAN SELECT, INC. 295 WEST CLAYTON STREET ATHENS, GEORGIA (706)

Transcription

1 ATHENS AREA HEALTH PLAN SELECT, INC. 295 WEST CLAYTON STREET ATHENS, GEORGIA (706) GROUP DENTAL RIDER This Rider amends the Evidence of Coverage to which it is attached and describes your Group Dental Benefits Plan. It includes the Dental Schedule of Benefits and sets out the limitations and exclusions of the Dental Plan. This coverage is based on the Group Healthcare Contract between Athens Area Health Plan Select, Inc. (hereinafter referred to as AAHPS ) and your Employer (the Policyholder ). The Dental Plan selected by your Employer is set out in the Benefit Summary attached to the Evidence of Coverage as Appendix A. The coverage under this Rider begins on the day your healthcare plan (as set out in that Evidence of Coverage) begins and terminates on the day benefits under the healthcare plan ends. The Schedule of Benefits below describes the Coinsurance, Deductibles, limitations, and Exclusions of this Dental Plan. Section I INTRODUCTION Your Employer has contracted with AAHPS to provide you the dental benefits coverage described in this Rider. This booklet includes a Schedule of Benefits and will help you understand your benefits and the operation of the AAHPS Group Dental Plan. This Plan is designed to assist you and your family members in achieving and maintaining good dental health at a lower cost. The Plan covers basic dental services, preventive care, and certain options provide limited orthodontic coverage. The Plan allows you to be treated by any Dentist you choose. There are four levels of coverage available under the Plan (High Option, Medium Option, Low Option, and Standard Option). The Contributory option chosen by your Employer or the Voluntary option chosen by you is described in the Benefit Summary that is attached to your Evidence of Coverage. For certain benefits you are required to pay a percentage of the charges called Coinsurance as set our in the Benefit Summary. You are also required to pay an annual Deductible before some benefits are paid. These terms are defined in the Definitions Section of this Rider or in the Evidence of Coverage which it amends. The amounts of the Coinsurance and Deductible are set out in the Benefit Summary. Dental Plans may be Contributory (your Employer pays a portion of the premium for dental coverage) or Voluntary (you pay the entire cost of the dental coverage). You should read this Rider carefully before seeking dental care so that you can understand the benefits provided and the limitations and Exclusions of the Plan. 1

2 Section II DEFINITIONS The following definitions apply to this Rider: Accidental Injury: Any unforeseen and unintended injury resulting from an accident but does not include chewing injuries. Affiliation Period: The period of time determined by the Policyholder that a member must be employed before becoming eligible for coverage under this Plan. See also Waiting Period. Allowable Charge/Allowable Expense: Any expense that does not exceed the Usual, Customary, and Reasonable (UCR) charge with that Provider for that service, and that is covered, at least in part, by the provisions of this dental plan. Allowable Charge Limitation: The Plan will not pay any amount that is in excess of the Allowable Charge as defined above. Annual Maximum: The maximum amount the Plan will pay for eligible expenses or services incurred by a covered person during the calendar year. Calendar Year: A period which begins January 1 st and ends December 31 st. For purposes of Deductibles, Out-of-Pockets and Annual Maximums, the Calendar Year period will apply. Claim Form: The standard forms utilized by dentists and other providers to file for services provided or a customized form provided by AAHPS to its members for the purpose of filing directly for services received. Coinsurance: The Member will be responsible for the coinsurance percentage set out in the Benefits Summary for all charges for covered dental services, after paying the applicable Deductible. Complaint: A written expression of concern by an enrollee or provider regarding the provisions of dental services. A Complaint concerns exclusions or limitations of treatments or services, eligibility issues, and other matters. Continuation of Coverage: Plan coverage may be continued, after the date that Coverage would otherwise end, by a Member at the Member's election upon meeting the requirements set out in Section X in the Evidence of Coverage. Contract or Group Healthcare Contract: The Group Healthcare Contract between AAHPS and Policyholder. 2

3 Contract Years and Contract Months: Are determined from the Effective Date of the Contract. Covered: Being eligible for and enrolled in the Group Dental Benefit Plan. Covered Services: The Dental Services provided to Members under the terms of the Contract and this Rider. Deductible: The amount that an individual Member or family must pay for Covered Dental services each calendar year before benefits for such services are paid. Any portion of the Deductible which is met within the last three months of the Calendar Year that applies to that Calendar Year s Deductible will carry-over and also apply to the Deductible for the next Calendar Year. Deferred Services: Dental services or treatments that are only covered after the Dental coverage has been in effect for a specified period of time as set out in the Benefit Summary. Dentist: A person currently licensed to practice dentistry and who is acting within the scope of their license. Dependent: A person listed on the Subscriber's Enrollment/Change Form who is: 1. the Subscriber's legal spouse; or 2. an unmarried Dependent Child, as defined below, of either the Subscriber or the Subscriber's spouse, who is: a. less than nineteen (19) years of age; b. whose principal residence is with the Subscriber (unless the Dependent resides with the other spouse according to a qualified medical child support order); c. is primarily dependent upon the Subscriber or the Subscriber's spouse for support and maintenance; d. is claimed as a dependent on the Subscriber's or the Subscriber's spouse's income tax return; and e. subject to the following conditions and limitations: (1) The term "Dependent Child" as used herein shall include any stepchild, legally adopted child or child placed in the Subscriber s home prior to adoption, or a child for whom the Subscriber is legal guardian. NOTE: Newborns and adopted children are automatically covered for thirty-one (31) days after birth or adoption or placement in the home prior to adoption. To continue coverage beyond thirty-one (31) days, unless the Subscriber is already enrolled under the Family Membership Plan, the Subscriber must apply for coverage by submitting an Enrollment/Change form to the Policyholder within the thirty-one (31) day period. 3

4 (2) An unmarried dependent child, regardless of age, who is incapable of self-support and became so incapacitated before attaining age nineteen (19) because of mental illness, mental retardation, developmental disability, or physical handicap, will be covered and when coverage of such child would normally terminate upon the child's nineteenth (19 th ) birthday, will continue to be covered as a Family Dependent, subject to the provision for extended coverage in Section XI. (3) Any unmarried dependent child who is between nineteen (19) and up to and including twenty-five (25) years of age, provided the child is a full-time student at a Post Secondary Educational Institution for at least five (5) calendar months or more in the calendar year or, if not so enrolled, would have been eligible to be so enrolled and was prevented from being so enrolled due to illness or injury. Full-time means a minimum of twelve (12) credit hours per semester or quarter. In-Network coverage for Healthcare Services outside the Service Area is limited to Emergency Care services as described herein. It is the responsibility of the Subscriber to provide proof of full-time student status on a semi-annual basis on a form furnished by AAHPS and completed by the registrar or similar official of the Post Secondary Educational Institution. The Subscriber must notify AAHPS when a Family Dependent is no longer a fulltime student. If a dependent child was prevented from being enrolled due to illness or injury, and is eligible to be claimed as a dependent on the Subscriber's federal income tax return, the child will be considered eligible until he or she is able to enroll as a full-time student or reaches up to and including twentyfive (25) years of age. Medical documentation will be required to extend this coverage. (4) In no event shall the term "Family Dependent" include: (a) any spouse or child who is eligible for Medicare, by reason of age (except, when the Subscriber remains employed on a full-time basis, the spouse may be entitled to remain covered as a Family Dependent); or (b) any spouse or child on active duty in the armed forces of any country, except for temporary duty of thirty-one (31) days or less. f. Those dependents for which you are ordered to provide coverage through a Qualified Child Support Order. Effective Date: The date from which eligible Group Members are approved by AAHPS to receive Dental Services, also called Eligibility Date. Eligibility Date: The date on which a particular Member is approved by AAHPS to receive Dental Services. 4

5 Eligible Employee: An active full-time employee, including an owner, sole proprietor, or partner, who works a minimum of thirty (30) hours on average per week for the Policyholder and who has completed any probationary period for employees and for whom the Policyholder deducts FICA taxes from his or her pay. Emergency: A medical condition of a recent onset and sufficient severity, including but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in (1) placing the patient s health in serious jeopardy, or (2) serious impairment to bodily functions, or (3) serious dysfunction of any bodily organ or part, or (4) with respect to a pregnant Member who is having contractions, that there is inadequate time to safely transfer her prior to delivery or that such transfer may pose a threat to the health or safety of the Member or her unborn child. Employer: The business that has entered into the Group Healthcare Contract with AAHPS to purchase dental coverage for its Eligible Employees and their Covered Dependents. The Employer is also the Policyholder for purposes of the Evidence of Coverage and this Rider. Enrollment/Change Form: The form completed by Subscribers requesting coverage from AAHPS which lists all Family Dependents to be covered on the Eligibility Date and provided by AAHPS to the Policyholder for distribution to Members who wish to add or delete a Family Dependent, or revise information contained in the enrollment record. Evidence of Coverage: The booklet which describes your group healthcare Plan policies, services, benefits, exclusions and limitations and to which this Dental Rider is attached as an optional Rider. In some cases the Evidence of Coverage may be referred as the Certificate of Coverage Exclusions: Specific conditions, circumstances, or treatments, devices, or medications listed herein that are not covered and for which this Plan will not provide benefit payments. Experimental or Investigative: Drugs, treatments, diagnostic tests, devices and/or procedures that are determined by AAHPS as not being the appropriate, acceptable standard treatment for the condition being treated or which have not been approved by the appropriate government agency and are not generally accepted forms of treatment according to national dental standards as reflected in published reports or articles in nationally recognized authoritative dental and scientific journals or literature. AAHPS will rely on the advice of dental consultants, the community standards of dental care, generally recognized dental publications, and government standards, regulations, or guidelines for government programs in making these determinations. A treatment or service that is determined to be Experimental or Investigative is not a Covered Benefit. Explanation of Benefits (EOB): A form sent to the covered Member after a claim for payment has been processed by AAHPS that explains the action taken on that claim. The explanation of benefits will include the amount that has been paid, the benefit available, the 5

6 reason for denying payment in whole or in part, and, if appropriate, the claims appeal process. Functioning Natural Tooth: See Sound Natural Tooth or Teeth. Grievance: A written complaint submitted by Members or other authorized representatives acting on behalf of the Member about any of the following: AAHPS s decisions, policies, or actions related to availability, delivery, or quality of dental services. Claims payment or handling or reimbursement for services. The contractual relationship between a Member and AAHPS. The outcome of an appeal of a non-certification. Group: The Policyholder s employees and Family Dependents who are eligible to enroll in the Group Dental Benefit Plan. The Group may be subdivided into classes to the extent permissible under federal and state law. Group Application Form: The form completed by the Group requesting coverage from AAHPS. Group Dental Benefit Plan: The AAHPS dental benefit plan that provides coverage to Subscribers and their Family Dependents pursuant to the applicable Contract between the Policyholder and AAHPS. Group Healthcare Contract: The Contract between AAHPS and the Policyholder. This Rider is a part of the Group Healthcare Contract. Identification Card: See Membership Card. Initial Enrollment Period: The period of time when an employee or Dependent first becomes eligible for coverage on either the effective date of the Plan or within thirty-one (31) days of the first date of employment, excluding the Affiliation Period. Injury: Bodily harm resulting from a non-occupational Accident. This term does not include chewing accidents. Member: An enrollee, Subscriber, or Dependent, who is covered by the AAHPS Dental Benefit Plan described in this Rider. Membership Card: The identification card that AAHPS issues to its Members showing that they are entitled to receive Dental Services. Possession of a Membership Card does not guarantee eligibility for dental coverage. Benefits and eligibility will be determined at the time claims are received. Verification of coverage prior to receiving services can be obtained through contacting the Member Services Department at AAHPS. 6

7 Membership Type: There are four (4) types of memberships offered to AAHPS Policyholders: 1. Single 2. Employee and Spouse 3. Employee and one dependent (spouse or one child) 4. Family Open Enrollment Period: The annual period during which AAHPS and the Policyholder agree that Subscribers and eligible Family Dependents may apply for coverage. Subscribers and Dependents may also be able to enroll during special enrollment periods. Orthodontic Treatment: The correction of a malocclusion of the mouth that is corrected by movement of the teeth through means of an active appliance. Orthodontic Treatment Plan: The Dentist s proposed or recommended plan of treatment submitted on AAHPS s form and which describes in sufficient detail the procedures and treatments, and the proposed timeframes involved in the correction of the malocclusion, and which sets out in detail the charges for each procedure or treatment, and which is accompanied by the medical record (including radiological and other diagnostic reports) which are needed by AAHPS to properly evaluate the treatment plan. Periodontics: The practice of Dentistry pertaining to prevention, diagnosis, and treatment of diseases and conditions of the gums and bones which surround and support teeth. Plan: This dental benefit plan underwritten by Athens Area Health Plan Select, Inc. (AAHPS). Policyholder: The employer or other entity with whom the Contract is made and who agrees to collect and pay the applicable premium to AAHPS on behalf of all of its Subscribers and Family Dependents. Post Secondary Education Institution: An institution of higher learning having an organized curriculum and requiring class attendance for a minimum number of hours per quarter or semester, and which is accredited by a government agency or nationally or regionally recognized accreditation association, or which is approved for educational benefits by either the Georgia Department of Education, the United States Veteran s Administration, or other state or federal agency. This term includes, but is not limited to, colleges, universities, vocational or technical schools, professional or graduate schools. This term does not include cosmetology school, barber school, equestrian school, sports school, bartender school, or other similar training. Premium Contribution: The premium that the Policyholder pays on behalf of, or collects from, Subscribers and submits to AAHPS. 7

8 Preventive Care: Proactive dental care designed to help people to achieve and maintain good dental health. It includes cleanings and other appropriate treatments and services Qualified Medical Child Support Order: An order by a court or government agency that requires a non-custodial parent to provide health care coverage to a child who does not usually reside with the parent being ordered to provide such coverage. Review Panel: A committee composed of the Director of Claims, Director of Member Services, Director of Quality and Utilization, and the Director of Network Development, which review complaints about non-dental issues, such as Exclusions and limitations of the Plan, and eligibility determinations. Rider: An agreement with the Policyholder, which amends the Contract. Sickness: Physical illness. Sound Natural Tooth or Teeth: Means a tooth or teeth which: has no fillings or cavities; or has fillings or cavities which do not undermine the tooth cusp; and has healthy and intact pulpal tissues; and has periodontal tissues showing no sign of active or chronic inflammation. AAHPS reserves the right to determine what is a sound natural tooth. AAHPS will evaluate each tooth separately. Special Enrollment Period: The period during which a Subscriber and/or Family Dependent may elect to enroll as described in Section III-C.2 (b) and, in the case of a new Family Dependent, as described in Section III-C.3(c). Spouse: A person of the opposite sex who is legally married to the Subscriber. Subscriber: An Eligible Employee of the Policyholder who is entitled to participate in dental benefits through the Policyholder and who meets such eligibility requirements (such as length of service, active employment, etc.) as may be imposed by the Policyholder, subject to any Continuation of Coverage that may be available. Subscriber Premium Contribution: The amount paid or payable periodically by a Subscriber to pay any part of the premium. Temporomandibular Joint Dysfunction (TMJ): Disease or deformity of the temporomandibular joint. Totally Disabled: In the case of an adult Member, Totally Disabled means that he or she, as a result of illness or injury, is unable to perform the usual tasks required of his or her employment and is not able to be employed for wages or profit. A Dependent child is considered Totally Disabled when, as a result of injury or illness, he or she is wholly unable to engage in the normal activities of a person of the same sex and age. Usual, Customary, and Reasonable (UCR) as Determined by AAHPS: The amount of the charge that is based on the most frequent and ordinary charge for the same service or 8

9 treatment in the same geographic area by dental providers with similar training and experience that is within the scope of the law, in conformity with industry standards, and based on recognized levels of reimbursement by government agencies and not exceeding the appropriate limits based on standard industry methodology for the service or treatment provided. Waiting Period: The period of time that you have to wait after coverage is effective before certain benefits are covered. We, Us, Our and Ours: Athens Area Health Plan Select, Inc. You or Your: The Member receiving Dental Services under this Rider. For ease of reading these words are not capitalized in the text of this Rider. Section III Eligibility A. Eligibility. YOU MUST BE COVERED BY THE GROUP HEALTH BENEFIT PLAN TO BE ELIGIBLE FOR THIS GROUP DENTAL BENEFIT PLAN. 1. You are eligible for enrollment when you are: a. A Subscriber. b. A Dependent. 2. Except as otherwise provided herein, persons not entitled to coverage include: a. Persons who are in the armed forces of any government (except persons serving in the United States military for thirty-one (31) days or less). b. Any child born to a Subscriber's Dependent child. 3. You are employed full-time (30 hours or more on average per week) or you are an owner, sole proprietor, or partner who works 30 or more hours on average per week, and have completed any probationary period for employees and for whom the Policyholder deducts FICA taxes from your pay. 4. AAHPS has the right to request and be furnished with such proof as may be needed to determine eligibility status of a Member. 5. AAHPS may examine a Group's records including payroll records and an individual's employment, or Membership records in determining eligibility status for Membership. B. General Enrollment. 1. You may enroll yourself and your Dependents within thirty-one (31) days of your first day of employment and completion of any Policyholder required Waiting Period by completing an Enrollment/Change Form, available from either the Policyholder or AAHPS. The Policyholder shall give all newly 9

10 hired employees or Members of the Group AAHPS s Enrollment/Change Form and descriptive literature as soon as they become eligible for coverage. If Subscribers do not apply within thirty-one (31) days of the date they become eligible, they must wait until the next Open Enrollment Period or a Special Enrollment Period as provided in Paragraph C below to become Covered. 2. Changes to the original Enrollment/Change Form must be made by completing a Change of Status Form, which will be made available by AAHPS to the Policyholder for distribution to you. The Policyholder agrees to promptly send AAHPS all Enrollment/Change Forms and to notify AAHPS if there is any change in any Subscriber's eligibility for coverage from AAHPS. AAHPS is not responsible for errors due to the failure of the Policyholder or the Subscriber to give timely notice of changes. 3. Unless otherwise agreed to by AAHPS and the Policyholder, your coverage shall take effect on the Effective Date of the Contract, provided that you have satisfied the requirements of this Section. Subscribers and their Family Dependents eligible to enroll in the Group Dental Benefit Plan after the Effective Date shall be enrolled in the Group Dental Benefit Plan on the Eligibility Date agreed upon by both the Policyholder and AAHPS and the first month's premium is paid on behalf of the Subscriber and the Family Dependents. 4. You may enroll in the Group Dental Benefit Plan by applying for coverage during the Open Enrollment Period, which is the thirty (30) day period preceding the anniversary date of the Contract (except for Special Enrollment) upon meeting the eligibility requirements of this Plan, or during special Open Enrollment Periods agreed upon by both the Policyholder and AAHPS. C. Special Enrollment 1. If you and/or your Family Dependents are otherwise eligible for coverage and you and/or your Family Dependents did not enroll in the Group Dental Benefit Plan pursuant to general enrollment as set forth in paragraph B of this Section III, you may be eligible for Special Enrollment described in subparagraphs 2 and 3 below. 2. Subscriber and/or Family Dependents who initially decline coverage within the first thirty-one days (31) of the date they became eligible. a. If you and/or your Family Dependents are otherwise eligible for coverage but declined enrollment within the first thirty-one (31) days of the date you became eligible to enroll, you may enroll during a Special Enrollment Period. Such enrollment is effective on the Effective Date of Special Enrollment, provided the following conditions are satisfied: (1) When you or your Family Dependent declined coverage, you stated in writing submitted to the Policyholder and supplied to AAHPS that coverage under another group health plan or other 10

11 health insurance coverage was the reason for declining enrollment; (2) The other coverage was COBRA continuation coverage under that other group health plan and such coverage has been exhausted; (3) The other coverage was terminated as a result of loss of eligibility for the coverage or Policyholder contributions towards the other coverage have terminated; and (4) You or your Dependent requests such enrollment not later than thirty-one (31) days after the date of exhaustion or termination of the credible coverage. b. For purposes of this subparagraph 2, the Special Enrollment Period is the period ending thirty-one (31) days after the exhaustion of COBRA coverage or the termination of the other coverage as a result of loss of eligibility or cessation of employer contributions toward the other coverage. c. For purposes of this subparagraph 2, the Effective Date of Special Enrollment shall be the first day of the first calendar month beginning after the date the Enrollment Form is received by the Policyholder or the day after the other coverage terminated if allowed by the Policyholder and if the enrollment form is received by the Policyholder within thirty (30) days of the termination. 3. New Family Dependents a. If you are enrolled and have a new Dependent as a result of a marriage, a birth, adoption of a child, or the placement of a child for adoption with you, you may enroll your new Family Dependents during a Special Enrollment Period. Such enrollment is effective as of the Effective Date of Special Enrollment. NOTE: Newborns and adopted children are automatically covered for thirty-one (31) days after birth, or adoption, or placement in the home for adoption. To continue coverage beyond thirty-one (31) days, unless the Subscriber is already enrolled under the Family Membership Plan, the Subscriber must apply for coverage by submitting an Enrollment/Change form to the Policyholder within the thirty-one (31) day period. b. If you and/or your spouse are not enrolled and have a new Family Dependent, provided you and your spouse are otherwise eligible, then (i) just you, (ii) you and your spouse, or (iii) you, your spouse and the new Family Dependent, may enroll during a Special Enrollment Period. Such enrollment is effective as of the Effective Date of Special Enrollment. c. For purposes of this subparagraph 3, the Special Enrollment Period is the thirty-one (31) day period beginning on the date of the marriage, birth, adoption or placement for adoption of the new Family Dependent. d. For purposes of this subparagraph 3, the Effective Date of Special Enrollment is: 11

12 (1) In the case of marriage, if the Member requests such enrollment not later than thirty-one (31) days following the date of the marriage or the date dependent coverage is first made available, whichever is later, coverage of the spouse shall commence not later than the first day of the first month beginning after the date the request for enrollment is received; (2) In the case of the Family Dependent s birth, the date of such birth; adoption or placement for adoption of the new Family Dependent. (3) In the case of the Family Dependent s adoption or placement for adoption, the date of such adoption or placement for adoption. In all cases of a change in eligibility or dependent status the Policyholder must notify AAHPS within ten business days from receipt of such information from the Employee or Dependent. Section IV DENTAL BENEFITS Plan Maximums: All Plans have a $5,000 lifetime maximum benefit. The Dental Plan you have is set out in the Benefit Summary attached to this Rider. The coverages, deductibles, coinsurance and limitations and Exclusions are described in the Benefit Summary. NOTE: For Dental Plans which include an orthodontic benefit an Orthodontic Treatment Plan must be submitted before orthodontic treatment is received or no benefits will be paid. Section V EXCLUSIONS: The Following Dental Expenses Are Not Covered: 1. Dental services or treatments that are not specifically described herein as Covered Services. 2. Expenses in excess of the usual, customary, and reasonable amount normally charged by provider in the same specialty and geographic region. 3. Any dental services and supplies which are covered in whole or in part, under any other part of the plan or under another plan of benefits provided by an Employer. 4. Dental check-ups or dental screening by your employer, a school or government. Services that are paid for by a government or provided without charge in the absence of this coverage. 12

13 5. Charges covered under both the Dental and Healthcare Plan. Dental benefits are limited to the excess not paid by the Healthcare Plan but the dental benefit will not exceed the amount normally paid by the Dental Plan. 6. Treatment by other than a dentist except for treatment by a licensed dental hygienist supervised by a dentist. 7. Dietary planning or instructions for plaque control, oral hygiene and diet. 8. Prescription drugs, non-prescription drugs, vitamins, or dietary supplements. 9. Services or supplies cosmetic in nature necessary as a result of an accident occurring while coverage was not in effect under this Plan. 10. Any dental procedures which are undertaken primarily for cosmetic reasons, or dental care to treat accidental injuries, congenital or developmental malformations. Dental benefit plans are only intended to provide coverage for the treatment of dental disease and other tooth related problems. Services rendered for cosmetic purposes are not covered. 11. Charges for hospitalization or administration of general anesthesia, whether in a hospital or in the dentist s office. 12. Replacement of a lost, missing or stolen prosthetic device. 13. Service or supplies such as dentures, crowns, inlays, onlays, bridgework or any other appliance used to increase vertical dimension, to restore occlusion, bite registration, or bite analysis. 14. Devices or appliances to control or eliminate harmful habits including, but not limited to, grinding teeth. 15. Services, supplies and appliances in connection with treatment for Temporomandibular Joint Syndrome (TMJ). Certain services or treatments for TMJ are covered under the medical benefits described in the Evidence of Coverage. 16. Treatment or services resulting from war or an act of war or from participation in a riot or any criminal activity. 17. Treatment or services resulting from an injury while employed for wage or profit, regardless of whether or not a claim is filed under Workers Compensation or a similar law. 18. Treatment or service for which the covered individual has no financial liability or would be provided at no charge in the absence of coverage. 19. Any Experimental or Investigative treatment or service which is not generally accepted as appropriate for the condition being treated by the dental or medical community. 20. Services provided by any person related to or who resides with the covered individual. 21. Fluoride treatment after age Application of sealants for dependent children after age Orthodontic treatment including preliminary diagnostic procedures, removal of teeth and correction of occlusion provided, however, limited orthodontic benefits are provided by the High Option with Orthodontics of Contributory Plans. 13

14 24. Dental implants, lost or stolen appliances, precision or semi-precision attachments, over dentures or customized prosthesis, dentures duplication, or other customized attachments. 25. Charges for alveolectomy also known as alveoloplasty. 26. Charges for missed appointments. 27. Completion of claim forms. 28. Charges incurred while coverage provided by this Rider is not in effect. 29. Missing Tooth Rule: No coverage is provided for the first installation of bridges, removable or fixed) or dentures to replace one or more teeth that were lost or removed prior to the effective date of coverage under this Rider. 30. Charges for precious metals or precious gems attached to or implanted in teeth or appliances. 31. Services not listed in the Schedule of Benefits are not covered. 32. Any claims submitted more than one year after the date of service. All other terms and provisions of the Evidence of Coverage remain in effect unless specifically amended by the terms of this Rider. This Rider terminates upon the date the coverage provided by the Evidence of Coverage to which it is attached terminates. Athens Area Health Plan Select, Inc. Jeff Kunkle, Executive Director 14

15 APPENDIX A BENEFIT SUMMARY 15